I sure agree the deceased had access to lots of meds – and his demise is one reason I almost never start benzodiazapines (the Valium family) on a daily basis in new patients (and only start them on a prn basis in extraordinary circumstances.

As Oxycontin and other long-acting opiate agonists are prescribed with increasing frequency in the general population, an increasing number of accidental OD”s are reprorted – apparently due to the synergistic SE’s of these (and other) meds.

I’m not concluding Mr. Ledger had any particular psych diagnosis (and of course I’m not suggesting you are).

Over the four years I recently did community mental health, I was struck by the number of patients who demonstrated voracious appetites for prescription RX, were not selling the RX on street, had serum levels consistent with what they said they were taking – and still were tormented by unrelieved insomnia/racing thoughts/emotional anguish.

Almost all these folks had undiagnosed major psych disease (almost always bipolar) and – as soon as they received accurate diagnosis/ evidence-based treatment – stopped their “pill popping”. They’d been gobbling meds to relieve their suffering – not to cop a buzz.

For patients with bipolar disorder – in which disturbed sleep (or no sleep) is a diagnostic criteria of the mixed/manic phases, and impulsivity/impaired judgement become more severe as mixed/manic sx increase – I’ve give up even trying to distinguish (unconscious) suicidal behavior from reckless behavior. I just try to ensure that what I (and other docs) prescribe for my patient won’t cause accidental OD even if the patient takes a few days of meds “because I just needed to sleep”.

Of course, this also explains why if I were to resume psychopharm practice I wouldn’t be taking on bipolar patients – the level and frequency of MD contact they (appropriately) require to adjust meds to theraputic levels often requires the sort of 24/7 back-up that only university-based clinics can sustainably provide.

As only a few days go by between lay people tellng me about loved ones / friends / colleagues who apparently meet criteria for BAD – yet can’t even get a decent psych assessment – I do fantasize about a limited practice confined to psych diagnoses.

[Immodestly enough, I’m sure that service would help - but I’d still end the day wanting to scream ’cause of all the years the patients had suffered before someone took the fifty minutes required to do a decent frakkin history and ask questions from a validated psych dx instrument.

Again, this has nothing to do with Mr. Ledger’s individual history or diagnosis.

His tragic death - just as tragic as that of any person - simply brings up one of my greatest dissatisfactions with psych practice and the use of psychoactive drugs.]

To me, it has everything to do with the fact that psychoactive meds and opiate agonists are immensely powerful tools. Like all powerful tools, can cause injury and death when used in the wrong fashion – and will almost certainly do so when used for the wrong task.

Some docs prescibe these powerful tools carefully and mindfully – but until all do, OD’s from multiple psych/analgesic meds used concurrently will keep on killing.

Kind of a hard sell.

I was initially irritated at what I took to be an arrogant, obscurely worded comment implying that any of us who believed in choosing the lesser of two evils, or didn’t recognize the evil, were thoughtless morons.

You said ‘The wingnuts are coming, the wingnuts are coming’ after Hillary Clinton!

I said bring the old geezers on.

You said, I’m not talking about old winuttia, I’m talking about new wingunttia.

I said that new wingnuttia is the same as old wingnuttia, and that new wingnuttia (which is the same as old wingnuttia) will be ever so handicapped by the fact that their guy (McCain) is not even their guy. And even if he happened to be “their guy” he has lost his gitty-up. More handicap.

So they seek the right pill or combination of pills to solve issues that probably in the realm of Dr Kirk. Docs have no time, poor record keeping in their offices, no references from different RX chains and people are seeking help and not getting the answers they really need.

At UCLA I tried hard to avoid celeb/med media (and even harder to avoid being referred celebs as pts. Sorry – I don’t do house calls for the able bodied ‘just cause their manicurist will).

FOr whatever reason, I haven’t been able to escape hearing that the unfortunate Mr. Ledger complained of sleep dififcultie. Try as I may, I can’t seem to dump the factoid he was complaining about profound sleep difficulties even on the other side of the pond.

My shrinky sense tingles whenever I hear a “complaint” (symptom) of profound insomnia in those without medical causes for same.

Once underlying disease is ruled-out, profound recurrent sleep difficulties are a “red flag” to look for psych causes: either secondary (from prescribed and/or recreational substances) or major psych diagnoses (esp bipolar disorder).

Sadly for patients, more than 90% of psychoatice drugs are prescribed by non-shrink MD’s. ALthough some have the info base to screen for/diagnose major psych dx’s, most don’t. Even fewer have the time to do so.

These facts – coupled with the sad facts that most shrinks still don’t use validated diagnostic instruments (best way to obtain accurate diagnoses) condemn pts with bipolar disorder to a delay of twelve years between their first encounter with mental health care and having their BAD dx’d.

I’m sure not saying Mr. Ledger meets dx criteria for bipolar – his death is a tragedy whatever the dx (or absence of same).

I am beyond frustration at the widespread prescribing of psychoactive substances to treat symptoms when neither the doc or patient have established a diagnosis.

“Narcotics” is a tricky term: lives in legal space (DEA – all manner of “bad drugs”) and medical space (opium or drugs that act like it). The medical term opiate agonist decribes natural and sythetic opium-like drugs. These drugs can cause respiratory depression; Narcan reverses this.

Benzodizapines (the Valium family) also can cause respiratory depression; flumazenil can reverse this.

[Once a patient has suffered organ failure/brain death from respiratory depression, neither anatagonist (naloxone/flumazenil) will help…]

Hope this helps.

I keep trying to write a lay-person’s guide to bipolar dx/tx for a Lake post, but the misdignosis and resultant delay/suffering so irritates me as to be an aversive stimulus.

Gotta run – I think I smell cheese around the corner…

Besides, Vince Foster was one of dozens of wing nut conspiracies. If those clowns want to play that game…I think someone is ready for them.